Medicaid Rate. Primary Fee Schedule. Secondar y Fee Schedule. 8/2011 Commercial Yes, 100% of Anthem NE Regional Custom FS

Transcription

1 Health Plan State Contract Effective Date Anthem Anthem BCBS CT, NH, ME Lines of Business Anthem BCBS NH 8/2011 Medicare Advantage Empire BCBS Healthplus Medicare Rate Medicaid Rate Primary Fee Schedule Secondar y Fee Schedule Medicare Year Medicaid Year Custom Fee Schedule 8/2011 Commercial Yes, 100% of Anthem NE Regional Custom FS NY 10/2015 All Lines of Business Carveouts Miscellaneous Codes Covered Services No Yes, 100% of NH Medicare FS No 65% 100% Medicare Medicaid 2015 Prevailing No No Empire BCBS NY 6/2006 HMO Yes, 100% of Empire BCBS Commercial FS Empire BCBS NY 6/2006 Medicare Advantage Aetna Yes, 100% of Empire BCBS Medicare Advantage FS Aetna NJ 12/2010 Self-Insured Yes, 100% of Aetna National FS No No DMEPOS No Aenta NJ 12/2010 Fully-Insured Yes, 100% of Aetna National FS (DME); 100% of NJ Medicare FS (O&P) Aetna NY 12/2010 Managed Choice POS, Medicare-Elect Choice, Medicare-PPO, HMO, Open Choice PPO, NYC Community Plan Aetna Better Health Yes, 100% of Aetna National FS(DME); 100% of Aetna Market FS(O&P) NY 12/2014 Medicaid Yes, 95% of Aetna Medicaid Market FS No No All services not otherwise identified are 100% of Aetna Market FS DMEPOS No

2 Health Plan State Contract Effective Date Aetna Better Health Lines of Business NY 12/2014 DUAL Programs, FIDA Medicare Rate Medicaid Rate Primary Fee Schedule Secondar y Fee Schedule Medicare Year Medicaid Year Custom Fee Schedule Carveouts Miscellaneous Codes Covered Services 75% 95% Medicare Medicaid 2012 Prevailing No No Cost + 10% DMEPOS Affinity NY 4/2011 Medicaid, CHIP, - 84% Medicaid No Yes (see Cost + 50% DMEPOS FHP Affinity NY 4/2011 Medicare 84% - Medicare No No Ultimate, QHP, Medicare Solutions Agewell NY 12/2013 FIDA 75% 100% Medicare Medicaid 2012 Prevailing No No Cost + 25% DMEPOS Archcare NY 11/2012 MLTC - 90% Medicaid - Prevailing Prevailing No No Cost + 50% DMEPOS BCBS of Western NY NY 8/2011 All Lines of Business Yes, 100% of Anthem NE Regional Custom FS No DMEPOS 75% - Medicare - Prevailing - No No DMEPOS Crystal Run NY 6/2015 Commercial, Medicare Crystal Run NY 6/2015 Medicaid - 90% Medicaid - - Prevailing No Yes (see Fidelis Care NY 1/2014 Health Benefit - 74% - Medicaid - Prevailing No No Exchange, QHP Fidelis Care NY 5/2011 Medicare 70% - Medicare - Prevailing - No No Cost + 25% DMEPOS Fidelis Care NY 1/2015 FIDA 70% 70% Medicaid Medicare Prevailing Prevailing No No Cost + 35% DMEPOS Fidelis Care NY 5/2011 Medicaid, MLTC, ALIESSA Emblem - 70% Medicaid - - Prevailing No No Cost + 35% DMEPOS GHI NY 12/2008 All Lines of 65%(DMEPOS); - Medicare No Yes (see 60% of UCR DMEPOS Business 72% (Ostomy) rate HIP NY 9/2008 All Lines of 65%(DMEPOS); 100% Medicare Medicaid 2015 Prevailing No Yes (see 60% of UCR DMEPOS Business 72% (Ostomy) rate Guildnet NY 1/2012 MLTC - 88% - Medicaid - Prevailing No No Cost + 30% O&P only Hamaspik NY 11/2013 MLTC - 90% - Medicaid - Prevailing No No Healthcare Partners NY 7/2012 Commercial, POS, Medicare, PPO, ASO 65%(DME);75% (O&P) - Medicare - Prevailing Prevailing No No Healthcare NY 7/2012 Medicaid - 100% Medicaid - - Prevailing No No DMEPOS Partners Healthfirst NY 7/2015 All Lines of 65%(DME);68% 100% Medicare Medicaid Prevailing Prevailing No Yes (see 60% of MSRP DMEPOS Business (Enteral);68%(O &P);68%(Diabet ic Shoes) appendix rate Senior Health NY 7/2015 MLTC - 100% Medicaid - Prevailing - No Yes (see Partners Independenc e Care Systems NY 9/2012 MLTC 80% 100% Medicaid Medicare 2015 Prevailing No No Cost + 25% O&P only

3 Health Plan State Contract Effective Date Independent Health Lines of Business NY 11/2016 Commercial, Medicare, and Self Funded (ESI) Medicare Rate Medicaid Rate Primary Fee Schedule Secondar y Fee Schedule Medicare Year Medicaid Year Custom Fee Schedule Carveouts 82% - Medicare - Jan No Yes (see Miscellaneous Codes Independent NY 11/2016 State Products 80% - Medicaid - Jan No Yes (see Cost + 25% DMEPOS Health Local 1199 NY 3/2012 All Lines of Yes, 100% of - - O&P only National Benefit Fund Business 1199 FS (O&P Only) Magnacare NY 6/2015 All Lines of Yes Yes (see Business Metroplus NY 6/2012 All Lines of - 75% Medicaid - Prevailing - No No Cost + 35% DMEPOS Business Montefiore NY 11/2011 HMO 65% - Medicare - Prevailing - No No If not on DMEPOS CMO Medicare FS, then reimbursement will be negotiated prior to rendering services Montefiore NY 1/2014 MLTC - 100% - Medicaid - Prevailing No No CMO Multiplan NY 8/2006 PHCS Yes No Oscar T, 7/2016 Commercial 72% - Medicare No Yes (see Cost + 25% DMEPOS CA Oscar NY 1/2017 Commercial 72% - Medicare No Yes (see Cost + 25% DMEPOS Partners NY 4/2016 FIDA 75% 100% Medicare Medicaid Prevailing Prevailing No No Cost + 25% DMEPOS Health Plan Qualcare NJ 5/2013 All Lines of Business 70%(CPAP/Bipa p,o&p, Woundcare); 50%(DME & Resp.); 100% (A-codes w/o wound care) - Medicare No No 60% of UCR rate DMEPOS Senior Whole Health Senior Whole Health VillageCare Max Cost + 25% NY 6/2014 MLTC - 100% Medicaid - - Prevailing No No NY 6/2014 All non-mltc lines of business NY 11/2011 All Lines of Business Covered Services DMEPOS 80% 100% Medicare Medicaid Prevailing Prevailing No No Cost + 20% DMEPOS 75% 100% Medicaid Medicare Prevailing Prevailing No Yes (see Cost + 25% DMEPOS VNS Choice NY 10/2016 All Lines of Business 72% 100% Medicare Medicaid No Yes (see Cost + 25% DMEPOS

4 Health Plan State Contract Effective Date WellCare Health Plans, Inc. Wellcare Health Plan of NY Wellcare Health Plan of NJ Wellcare Health Plan of NJ Lines of Business NY 7/2014 Medicaid, CHIP, Medicare, MLTC Medicare Rate Medicaid Rate Primary Fee Schedule Secondar y Fee Schedule Medicare Year Medicaid Year Custom Fee Schedule Carveouts 72.5% 100% Medicare Medicaid Prevailing Prevailing No Yes (see NJ 4/2016 Medicaid - 85% Medicaid - - Prevailing No Yes (see NJ 6/2015 Medicare 72% Medicare - Prevailing - No Yes (see Easy Choice CA 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Harmony IL 5/2015 Medicaid - 91% Medicaid - Prevailing - No Yes (see Health Plan Harmony IL 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Health Plan Missouri Care MO 5/2015 Medicaid - 88% Medicaid - - Prevailing No Yes (see Inc. Ohana Health HI 5/2015 Medicaid - 95% Medicaid - - Prevailing No Yes (see Plan Ohana Health HI 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Plan Windsor SC 6/2015 Medicaid - 92% Medicaid - - Prevailing No Yes (see Health Plan Windsor SC 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Health Plan Windsor MS 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Health Plan Windsor TN 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Health Plan Windsor AR 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Health Plan Wellcare CT 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see Health Plan of CT Wellcare Health Plan of LA Wellcare Health Plan of T LA 6/2015 Medicare 72% - Medicare - Prevailing - No Yes (see T 6/2015 Medicare 69% - Medicare - Prevailing - No Yes (see Miscellaneous Codes Cost + 25% Covered Services DMEPOS

5 I. Appendix 1: Code Exceptions Affinity - Medicaid, CHP, & FHP HCPCS Percentage Flat Rate A6550 $ E2402 $ BR By report 70% of Charges E0465 $ E0466 $ Crystal Run All lines of Business HCPCS Percentage Flat Rate A4230 $ A4231 $ A4232 $ A9276 $ A9277 $1, E0784 $6, Independent Health (Self-Funded, Medicare Advantage, and Commercial) HCPCS Percentage Flat Rate E0784 $600.00/month up to 10 months Independent Health (Self-Funded, Medicare Advantage, Commercial, and State Products) A4230 A4231 A4232 HCPCS Percentage Flat Rate $22.50 each $6.50 each $6.50 each Independent Health (State Products) HCPCS Percentage Flat Rate E0784 $ Metroplus All Lines of Business HCPCS Percentage Flat Rate S1040 $ 1,105.89

6 Healthfirst/Senior Health Partners *Rates effective 7/1/2015 HCPCS Percentage Flat Rate A4310 $ 3.03 A4311 $ 4.00 A4312 $ 4.69 A4314 $ 5.25 A4315 $ 8.71 A4316 $ 6.89 A4320 $ 1.60 A4322 $ 0.85 A4326 $ 4.89 A4328 $ 0.35 A4330 $ 7.71 A4331 $ 0.43 A4332 $ 0.07 A4333 $ 1.37 A4334 $ 2.09 A4335 $ 0.31 A4338 $ 0.97 A4340 $ 1.15 A4344 $ 2.23 A4346 $ 1.26 A4349 $ 0.53 A4351 $ 0.80 A4352 $ 0.99 A4353 $ 2.24 A4354 $ 9.60 A4355 $ 3.14 A4520 $ 0.46 A5102 $ A5112 $ A5113 $ 1.72 A5114 $ 1.72 A4554 $ 0.16 T4521 $ 0.33 T4522 $ 0.29 T4523 $ 0.39 T4524 $ 0.52 T4525 $ 0.42 T4526 $ 0.36 T4527 $ 0.40 T4528 $ 0.52 T4529 $ 0.24

7 T4530 $ 0.23 T4531 $ 0.32 T4532 $ 0.36 T4533 $ 0.32 T4534 $ 0.39 T4535 $ 0.14 T4537 $ 8.20 T4541 $ 0.29 T4542 $ 0.29 T4543 $ 0.86 Oscar Insurance Corporation, and all applicable affiliates HCPCS Modifier Flat Rate A4230 NU $ A4231 NU $ A4232 NU $ A9276 NU $ A9277 NU $ 1, E0651 NU $ 1, E0651 RR $ E0652 NU $ 4, E0652 RR $ E0784 NU $ 6, K0606 RR $ 3, WellCare Health Plans, Inc. and all applicable affiliates HCPCS Percentage Flat Rate A4230 $ A4231 $ A4232 $ A9276 $ A9277 $1, E0784 $6, WellCare Health Plan of NJ - Medicaid HCPCS Modifier Flat Rate A4206 $ 0.29 A4207 $ 0.32 A4208 $ 0.29

8 A4209 $ 0.98 A4210 $ A4212 $ A4213 $ 0.62 A4215 $ 0.42 A4218 $ 0.96 A4230 $ A4231 $ A4232 $ A4250 $ A4252 $ 4.23 A4258 $ A4265 $ 3.25 A4281 $ 4.62 A4282 $ A4283 $ 2.92 A4284 $ 6.64 A4285 $ 9.72 A4286 $ 6.32 A4300 $ 4.69 A4305 $ A4306 $ A4326 $ 9.43 A4327 $ A4330 $ 5.40 A4333 $ 2.79 A4362 $ 3.47 A4364 $ 2.78 A4372 $ 4.29 A4373 $ 6.43 A4407 $ 8.73 A4408 $ 9.38 A4409 $ 6.19 A4410 $ 8.59 A4414 $ 4.91 A4415 $ 5.98 A4455 $ 2.00 A4465 $ A4466 $ A4483 $ 4.97 A4550 $ 4.94

9 A4556 $ A4557 $ A4558 $ 4.11 A4561 $ A4562 $ A4565 $ A4566 $ A4570 $ A4613 $ A4614 $ A4616 $ 0.08 A4627 $ A4628 $ 3.40 A4629 $ 4.21 A4630 $ 5.74 A4635 $ 4.09 A4636 $ 3.66 A4637 $ 1.76 A4640 $ A4653 $ 0.58 A4657 $ 0.61 A4660 $ A4663 $ A4670 $ A4680 $ A4750 $ A4772 $ A4773 $ A4860 $ 3.44 A4911 $ 7.52 A4928 $ A4929 $ 1.16 A5051 $ 2.06 A5052 $ 1.48 A5053 $ 2.03 A5054 $ 1.81 A5055 $ 1.42 A5061 $ 4.06 A5062 $ 2.21 A5063 $ 2.99 A5072 $ 4.03

10 A5073 $ 3.37 A5081 $ 3.70 A5200 $ A6010 $ A6011 $ 2.27 A6021 $ A6022 $ A6023 $ A6024 $ 5.61 A6154 $ A6196 $ 7.47 A6197 $ A6198 $ A6199 $ 5.38 A6203 $ 3.71 A6204 $ 6.91 A6205 $ A6206 $ 3.71 A6208 $ A6209 $ 7.44 A6210 $ A6211 $ A6212 $ 9.60 A6213 $ A6214 $ A6215 $ 2.38 A6216 $ 0.08 A6217 $ 0.43 A6218 $ 6.82 A6219 $ 0.83 A6220 $ 2.15 A6221 $ 5.61 A6222 $ 2.11 A6223 $ 2.40 A6224 $ 3.59 A6228 $ 3.69 A6229 $ 3.69 A6230 $ 3.69 A6234 $ 6.47 A6235 $ A6236 $ 27.70

11 A6237 $ 8.06 A6238 $ A6239 $ A6240 $ A6241 $ 2.60 A6242 $ 6.18 A6243 $ A6244 $ A6245 $ 7.37 A6246 $ A6247 $ A6248 $ A6250 $ 9.54 A6251 $ 2.00 A6252 $ 3.85 A6253 $ 6.51 A6254 $ 1.24 A6255 $ 3.06 A6256 $ 6.51 A6257 $ 1.55 A6258 $ 4.26 A6259 $ 9.54 A6260 $ A6261 $ 2.04 A6262 $ 4.93 A6266 $ 1.96 A6402 $ 0.12 A6403 $ 0.43 A6404 $ 0.49 A6442 $ 0.19 A6444 $ 0.49 A6446 $ 0.39 A6447 $ 0.64 A6448 $ 1.10 A6450 $ 5.24 A6502 $ A6503 $ A6504 $ A6505 $ A6506 $ A6507 $ 55.20

12 A6508 $ A6509 $ A6510 $ A6511 $ A6513 $ 1, A6544 $ A6545 $ A6549 $ A7030 $ A8002 $ A8003 $ A8004 $ A9274 $ A9276 $ A9277 $ 1, A9278 $ A9282 $ B4087 $ B4088 $ B4150 $ 1.05 B4152 $ 0.93 B4153 $ 4.23 B4154 $ 2.78 B4155 $ 5.34 B4157 $ 5.95 B4158 $ 1.12 B4159 $ 1.09 B4160 $ 1.05 B4161 $ 2.78 B4162 $ 8.38 E0162 $ E0186 $ E0187 $ E0190 $ E0236 $ E0240 $ E0241 $ E0242 $ E0243 $ E0244 $ E0245 $ 39.00

13 E0246 $ E0256 $ E0261 $ 1, E0274 $ E0277 $ 3, E0290 $ E0290 RR $ E0291 $ E0291 RR $ E0292 $ E0292 RR $ E0293 $ E0293 RR $ E0294 $ 1, E0294 RR $ E0295 $ 1, E0295 RR $ E0296 RR $ E0297 RR $ E0302 $ 4, E0303 $ 3, E0303 RR $ E0304 $ 8, E0304 RR $ E0371 $ 4, E0372 $ 4, E0455 $ E0455 RR $ E0462 $ 2, E0462 RR $ E0470 $ 2, E0471 $ 5, E0472 $ 5, E0485 $ 4.75 E0486 $ 4.75 E0603 $ E0604 $ E0625 $ E0641 $ 1, E0642 $ 4, E0700 $ 45.70

14 E0705 $ E0710 $ E0731 $ E0740 $ E0740 RR $ E0748 $ 3, E0755 $ E0762 $ E0781 $ 2, E0784 $ 6, E0791 $ 2, E0911 $ E0912 $ 1, E0947 $ E0948 $ E0948 RR $ E0969 $ E0983 $ E0984 $ E0988 $ 2, E0988 RR $ E1031 $ E1031 RR $ E1035 $ 7, E1035 RR $ E1038 $ E1038 RR $ E1039 $ E1039 RR $ E1220 $ E1231 $ E1231 RR $ E1232 $ 2, E1232 RR $ E1233 $ 2, E1234 $ 2, E1235 $ 2, E1235 RR $ E1236 $ 1, E1236 RR $ E1237 $ 1,979.75

15 E1237 RR $ E1238 $ 1, E1238 RR $ E1300 $ E1353 $ E1405 RR $ E1406 RR $ E1700 RR $ E1701 RR $ 9.42 E1702 RR $ E1800 RR $ E1805 RR $ E1810 RR $ E1812 RR $ E1815 RR $ E1820 $ E1820 RR $ 7.31 E1825 RR $ E1830 RR $ E1902 $ E2201 $ E2202 $ E2203 $ E2204 $ E2216 $ E2216 RR $ 4.91 E2217 $ E2217 RR $ 3.91 E2218 $ E2358 $ 0.95 E2362 $ E2378 RR $ E8000 RR $ E8001 RR $ E8002 RR $ K0005 $ 1, K0007 $ 1, K0009 RR $ K0011 RR $ K0012 RR $ K0017 $ 43.94

16 K0018 $ K0019 $ K0020 $ K0020 RR $ 2.56 K0038 $ K0039 $ K0040 $ K0041 $ K0043 $ K0044 $ K0045 $ K0046 $ K0047 $ K0050 $ K0050 RR $ 1.79 K0051 $ K0051 RR $ 2.89 K0052 $ K0053 $ K0065 $ K0071 $ K0073 $ K0077 $ K0098 $ K0105 $ K0108 $ 0.95 K0812 $ K0813 $ 2, K0814 $ 2, K0815 $ 3, K0816 $ 3, K0820 $ 2, K0821 $ 3, K0822 $ 3, K0823 $ 3, K0824 $ 4, K0825 $ 4, K0826 $ 5, K0827 $ 5, K0828 $ 6, K0829 $ 6,026.52

17 K0830 $ K0831 $ K0835 $ 3, K0836 $ 3, K0837 $ 4, K0838 $ 4, K0839 $ 5, K0840 $ 9, K0841 $ 4, K0842 $ 4, K0843 $ 4, K0848 $ 5, K0849 $ 4, K0850 $ 5, K0851 $ 5, K0852 $ 6, K0853 $ 6, K0854 $ 9, K0855 $ 8, K0856 $ 5, K0857 $ 6, K0858 $ 6, K0859 $ 7, K0860 $ 9, K0861 $ 5, K0862 $ 6, K0863 $ 9, K0864 $ 11, K0868 $ K0869 $ K0877 $ K0879 $ K0880 $ K0884 $ K0885 $ K0886 $ K0890 $ 3, K0891 $ 4, L0113 $ L0623 $ L0624 $

18 L0629 $ L0632 $ 1, L0634 $ L1001 $ L1499 $ L2035 $ L2861 $ L2999 $ L3031 $ L3160 $ L3224 $ L3225 $ L3677 $ L3891 $ L3999 $ L5782 $ 2, L5826 $ 2, L5856 $ 20, L5858 $ 14, L5961 $ 4, L7180 $ 35, L7181 $ 34, L7510 $ L7600 $ L8001 $ L8030 $ L8499 $ L8614 $ 13, L9900 $ T4535 $ 0.28 VNSNY CHOICE, and all applicable affiliates 80% of 2015 NY Medicaid HCPCS 2015 NY Medicaid Rate 80% A4554 $0.28 $0.22 T4521 $0.47 $0.38 T4522 $0.51 $0.41 T4523 $0.68 $0.54 T4524 $0.72 $0.58 T4529 $0.30 $0.24

19 T4530 $0.36 $0.29 T4533 $0.39 $0.31 T4535 $0.28 $0.22 T4537 $13.44 $10.75 T4539 $6.65 $5.32 T4540 $7.19 $5.75 T4543 $1.38 $1.10 Magnacare Category HCPCS Range Percentage (of Medicare) Diabetic A4206-A % Diabetic A5500-A % * Unlisted Diabetic A4206-A4290; A5500-A % Ostomy & Uro A4310-A % Ostomy & Uro A4356-A % Ostomy & Uro A4361-A % Ostomy & Uro A5051-A % Ostomy & Uro A5102-A % Ostomy & Uro A5120-A % DME All Other A-Codes and E-Codes 70% Notes <-Percent of Billed Charges, $1,500 max Unlisted DME All Other A-Codes and E-Codes 65% <-Percent of Billed Charges, $1,500 max C-Pap E0601NU $ less any RR amount C-Pap E0601RR 70% Bi-Pap E0470NU $ 1, less any RR amount Bi-Pap E0470RR 70% O&P L-Codes 80% Unlisted O&P L-Codes 75% Wheelchairs K-Codes 70% Unlisted Wheelchairs K-Codes 65% Enteral B-Codes (all enteral) 70% Unlisted Enteral B-Codes (Supplies & Equip.) 65% Unlisted Enteral B-Codes (Nutrition Formula) 65% Misc. Services Q-Codes not covered <-Percent of Billed Charges, $1,500 max <-Percent of Billed Charges, $1,500 max <-Percent of Billed Charges, $500 max $500 max (if above, subject to negotiation) <-Percent of Billed Charges, $1,500 max

20 Vision/Hearing V-Codes not covered Cranial Molding S1040 $ 2, All unlisted HCPCs and custom rehabilitation equipment that fall within the above descriptions with charges greater than $5,000 per item must be negotiated at the time of service. An acquisition invoice must accompany all items with charges greater than $5,000. * "Unlisted" refers to HCPCS not listed on the 2015 Medicare fee schedule.

21 II. Appendix 2: 2016 Medicare Fee Schedule Carve Out Codes VillageCareMax MLTC HCPCS Modifier Flat Rate A7005 NU $23.14 A7030 NU $ A7034 NU $84.40 A7035 NU $25.42 A7037 NU $28.13 E0143 NU $86.27 E0147 NU $ E0149 NU $ E0156 NU $18.97 E0163 NU $91.81 E0260 RR $ E0261 RR $98.26 E0277 RR $ E0431 RR $22.82 E0470 RR $ E0471 RR $ E0562 NU $ E0562 RR $21.60 E0601 RR $80.15 E0730 NU $ E0973 NU $73.32 E0990 NU $84.26 E1390 RR $ E2611 NU $ K0001 RR $42.93 K0003 RR $66.79 K0004 RR $ K0195 RR $12.86 K0822 RR $ K0823 RR $ K0825 RR $ *Rates are equivalent to 75% of 2015 Medicare Fee Schedule HealthFirst Medicare, FIDA HCPCS Modifier Flat Rate A7005 NU $20.05 A7030 NU $ A7034 NU $73.14 A7035 NU $22.03 A7037 NU $24.38 E0143 NU $74.76 E0143 RR $13.43

22 E0147 NU $ E0147 RR $35.75 E0149 NU $ E0149 RR $13.88 E0156 NU $16.44 E0156 RR $2.11 E0163 NU $79.57 E0163 RR $14.98 E0260 RR $87.35 E0261 RR $85.16 E0277 RR $ E0431 RR $19.77 E0450 RR $ E0460 RR $ E0461 RR $ E0463 RR $1, E0464 RR $1, E0470 RR $ E0471 RR $ E0562 NU $ E0562 RR $18.72 E0601 RR $69.47 E0730 NU $ E0973 NU $63.54 E0990 NU $73.02 E0990 RR $7.60 E1390 RR $ E2611 NU $ E2611 RR $19.42 K0001 RR $37.21 K0003 RR $57.88 K0004 RR $96.41 K0195 RR $11.14 K0822 RR $ K0823 RR $ K0825 RR $ *Rates are equivalent to 75% of 2015 Medicare Fee Schedule

23 III. Appendix 3: Code Exclusions GHI PPO HCPCS A4230 A4231 A4232 A4245 A4250 A4252 A4253 A4256 A4258 A4259 A9276 A9277 A9278 E0607 E0784 E2100 Excluded HIP (HMO) HCPCS A4230 A4231 A4232 A4245 A4250 A4252 A4253 A4256 A4258 A4259 A9276 A9277 A9278 E0607 E0784 E2100 Excluded

24 Independent Health (Self-Funded, Medicare Advantage, Commercial, and State Products) HCPCS A9276 A9277 A9278 E0424 E0431 E1392 E0433 E0434 E0439 E1390 E1391 K0738 Excluded